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Diabetes Prevention Program
Home       : Diabetes A-Z List of Topics and Titles : Insulin Resistance       and Pre-Diabetes  Insulin Resistance and Pre-Diabetes- What does insulin do?
- How are insulin resistance, pre-diabetes, and type                 2 diabetes linked?
- What causes insulin resistance?
- What are the symptoms of insulin resistance and                 pre-diabetes?
- Do you have insulin resistance or pre-diabetes?
- Can you reverse insulin resistance?
- Can medicines help?
- Hope Through Research
- Points to Remember

Insulin resistance is a silent condition that increases the chances               of developing diabetes and heart disease. Learning about insulin               resistance is the first step you can take toward making lifestyle               changes that will help you prevent diabetes and other health problems.             
What does insulin do?
After you eat, the food is broken down into glucose, the simple               sugar that is the main source of energy for the body's cells. But               your cells cannot use glucose without insulin, a hormone produced               by the pancreas. Insulin helps the cells take in glucose and convert               it to energy. When the pancreas does not make enough insulin or               the body is unable to use the insulin that is present, the cells               cannot use glucose. Excess glucose builds up in the bloodstream,               setting the stage for diabetes.

Being obese or overweight affects the way insulin works in your               body. Extra fat tissue can make your body resistant to the action               of insulin, but exercise helps insulin work well. 

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How are insulin resistance, pre-diabetes, and type 2 diabetes linked?
If you have insulin resistance, your muscle, fat, and liver cells               do not use insulin properly. The pancreas tries to keep up with               the demand for insulin by producing more. Eventually, the pancreas               cannot keep up with the body's need for insulin, and excess glucose               builds up in the bloodstream. Many people with insulin resistance               have high levels of blood glucose and high levels of insulin circulating               in their blood at the same time.

People with blood glucose levels that are higher than normal but               not yet in the diabetic range have "pre-diabetes." Doctors sometimes               call this condition impaired fasting glucose (IFG) or impaired glucose               tolerance (IGT), depending on the test used to diagnose it. In a cross-section of U.S. adults aged 40 to 74 tested during the period 1988 to 1994, 33.8 percent had IFG, 15.4 percent had IGT, and 40.1 percent had pre-diabetes (IGT or IFG or both).  Applying these percentages to the 2000 U.S. population, about 35 million adults aged 40 to 74 would have IFG, 16 million would have IGT, and 41 million would have pre-diabetes.

If you have pre-diabetes, you have a higher risk of developing               type 2 diabetes, formerly called adult-onset diabetes or noninsulin-dependent               diabetes. Studies have shown that most people with pre-diabetes               go on to develop type 2 diabetes within 10 years, unless they lose               5 to 7 percent of their body weight--which is about 10 to 15 pounds               for someone who weighs 200 pounds--by making modest changes in their               diet and level of physical activity. People with pre-diabetes also               have a higher risk of heart disease.

Type 2 diabetes is sometimes defined as the form of diabetes that               develops when the body does not respond properly to insulin, as               opposed to type 1 diabetes, in which the pancreas makes no insulin               at all. At first, the pancreas keeps up with the added demand by               producing more insulin. In time, however, it loses the ability to               secrete enough insulin in response to meals.

Insulin resistance can also occur in people who have type 1 diabetes,               especially if they are overweight.

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What causes insulin resistance?
Because insulin resistance tends to run in families, we know that               genes are partly responsible. Excess weight also contributes to               insulin resistance because too much fat interferes with muscles'               ability to use insulin. Lack of exercise further reduces muscles'               ability to use insulin.

Many people with insulin resistance and high blood glucose have               excess weight around the waist, high LDL (bad) blood cholesterol               levels, low HDL (good) cholesterol levels, high levels of triglycerides               (another fat in the blood), and high blood pressure, all conditions               that also put the heart at risk. This combination of problems is               referred to as the metabolic syndrome, or the insulin resistance               syndrome (formerly called Syndrome X). 
Metabolic Syndrome
Metabolic syndrome is defined by the National Cholesterol Education Program as the presence of any three of the following conditions:
- excess weight around the waist (waist measurement of more                       than 40 inches for men and more than 35 inches for women)   
- high levels of triglycerides (150 mg/dL or higher)   
-  low levels of HDL, or "good," cholesterol (below 40 mg/dL for men and below 50 mg/dL for women)  
-  high blood pressure (130/85 mm Hg or higher)   
-  high fasting blood glucose levels (110 mg/dL or higher)   

*Source:* National Cholesterol Education                     Program, Third Report of the Expert Panel on Detection, Evaluation,                     and Treatment of High Blood Cholesterol in Adults (Adult Treatment                     Panel III), National Heart, Lung, and Blood Institute, National                     Institutes of Health, May 2001. 

*Note:*  Other definitions of similar conditions have been developed by the World Health Organization and the Association of Clinical Endocrinologists.

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What are the symptoms of insulin resistance and pre-diabetes?
Insulin resistance and pre-diabetes usually have no symptoms. You               may have one or both conditions for several years without noticing               anything. If you have a severe form of insulin resistance, you may               get dark patches of skin, usually on the back of your neck. Sometimes               people get a dark ring around their neck. Other possible sites for               these dark patches include elbows, knees, knuckles, and armpits.               This condition is called acanthosis nigricans.

If you have a mild or moderate form of insulin resistance, blood               tests may show normal or high blood glucose and high levels of insulin               at the same time. 

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Do you have insulin resistance or pre-diabetes?
Anyone 45 years or older should consider getting tested for diabetes. If you are overweight and aged 45 or older, it is strongly recommended that you get tested. You should consider getting tested if you are younger than               45, overweight, and have one or more of the following risk factors:
-  family history of diabetes     
-  low HDL cholesterol and high triglycerides    
-  high blood pressure     
-  history of gestational diabetes (diabetes during pregnancy)                 or gave birth to a baby weighing more than 9 pounds    
-  minority group background (African American, American Indian,                 Hispanic American/Latino, or Asian American/Pacific Islander)               

Diabetes and pre-diabetes can be detected with one of the following               tests:

A **fasting glucose** test measures your blood glucose after               you have gone overnight without eating. This test is most reliable               when done in the morning. Fasting glucose levels of 100 to 125 mg/dL               are above normal but not high enough to be called diabetes. This               condition is called pre-diabetes or impaired fasting glucose,               and it suggests that you have probably had insulin resistance for               some time. IFG is considered a pre-diabetic state, meaning that               you are more likely to develop diabetes but do not have it yet.

A **glucose tolerance** test measures your blood glucose after               an overnight fast and 2 hours after you drink a sweet liquid provided               by the doctor or laboratory. If your blood glucose falls between               140 and 199 mg/dL 2 hours after drinking the liquid, your glucose               tolerance is above normal but not high enough for diabetes. This               condition, also a form of pre-diabetes, is called impaired glucose               tolerance and, like IFG, it points toward a history of insulin               resistance and a risk for developing diabetes.

These tests give only indirect evidence of insulin resistance.               The test that most accurately measures insulin resistance is too               complicated and expensive to use as a screening tool in most doctors'               offices. The test, called the euglycemic clamp, is a research tool               that helps scientists learn more about sugar metabolism problems.               Insulin resistance can also be assessed with measurement of fasting               insulin. If conventional tests show that you have IFG or IGT, your               doctor may suggest changes in diet and exercise to reduce your risk               of developing diabetes.

If your blood glucose is higher than normal but lower than the diabetes range, have your blood glucose checked in 1 to 2 years.
Lab Tests and What They Show- Blood glucose.  High blood glucose may be a sign that                 your body does not have enough insulin or does not use it well.                 However, a fasting measurement or oral glucose tolerance test                 gives more precise information.  
- Insulin.  An insulin measurement helps determine whether                 a high blood glucose reading is the result of insufficient insulin                 or poor use of insulin.  
- Fasting glucose.  Your blood glucose level should be                 lower after several hours without eating. After an overnight fast,                 the normal level is below 100 mg/dL. If it is in the 100 to 125                 mg/dL range, you have impaired fasting glucose or pre-diabetes.                 A result of 126 or higher, if confirmed on a repeat test, indicates                 diabetes.  
- Glucose tolerance.  Your blood glucose level will be                 higher after drinking a sugar solution, but it should still be                 below 140 mg/dL 2 hours after the drink. If it is higher than                 normal (in the 140 to 199 mg/dL range) 2 hours after drinking                 the solution, you have IGT or pre-diabetes, which is another strong                 indication that your body has trouble using glucose. A level of                 200 or higher, if confirmed, means diabetes is already present.

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Can you reverse insulin resistance?
Yes. Physical activity and weight loss make the body respond better               to insulin. By losing weight and being more physically active, you               may avoid developing type 2 diabetes. In fact, a major study has               verified the benefits of healthy lifestyle changes and weight loss.               In 2001, the National Institutes of Health completed the Diabetes               Prevention Program (DPP), a clinical trial designed to find the               most effective ways of preventing type 2 diabetes in overweight               people with pre-diabetes. The researchers found that lifestyle changes               reduced the risk of diabetes by 58 percent. Also, many people with               pre-diabetes returned to normal blood glucose levels.

The main goal in treating insulin resistance and pre-diabetes is               to help your body relearn to use insulin normally. You can do several               things to help reach this goal.
Be Active and Eat Well 
Physical activity helps your muscle cells use blood glucose because               they need it for energy. Exercise makes those cells more sensitive               to insulin.

The DPP confirmed that people who follow a low-fat, low-calorie               diet and who increase activities such as walking briskly or riding               a bike for 30 minutes, five times a week, have a far smaller risk               of developing diabetes than people who do not exercise regularly.               The DPP also reinforced the importance of a low-calorie, low-fat               diet. Following a low-calorie, low-fat diet can provide two benefits.               If you are overweight, one benefit is that limiting your calorie               and fat intake can help you lose weight. DPP participants who lost               weight were far less likely to develop diabetes than others in the               study who remained at an unhealthy weight. Increasing your activity               and following a low-calorie, low-fat diet can also improve your               blood pressure and cholesterol levels and has many other health               benefits.

Scientists have established some numbers to help people set goals               that will reduce their risk of developing glucose metabolism problems.
- Weight.  Body mass index (BMI) is a measure used to evaluate                 body weight relative to height. You can use BMI to find out whether                 you are underweight, normal weight, overweight, or obese. Use                 the  Body Mass Index Table  to find your BMI.       - Find your height in the left-hand column.   
  - Move across in the same row to the number closest to your weight.  
  - The number at the top of that column is your BMI. Check the                 word above your BMI to see whether you are normal weight, overweight,                 or obese. If you are overweight or obese, talk with your doctor                 about ways to lose weight to reduce your risk of diabetes.     Body Mass Index Table  For a printer-friendly version of               this table, use the pdf.* **Normal****Overweight****Obese**BMI192021222324252627282930313233343536**Height                  (inches)****Body Weight                   (pounds)**589196100105110115119124129134138143148153158162167172599499104109114119124128133138143148153158163168173178609710210711211812312813313814314815315816316817417918461100106111116122127132137143148153158164169174180185190621041091151201261311361421471531581641691751801861911966310711311812413013514114615215816316917518018619119720364110116122128134140145151157163169174180186192197204209651141201261321381441501561621681741801861921982042102166611812413013614214815516116717317918619219820421021622367121127134140146153159166172178185191198204211217223230681251311381441511581641711771841901972032102162232302366912813514214915516216917618218919620320921622323023624370132139146153160167174181188195202209216222229236243250711361431501571651721791861932002082152222292362432502577214014715416216917718419119920621322122823524225025826573144151159166174182189197204212219227235242250257265272741481551631711791861942022102182252332412492562642722807515216016817618419220020821622423224024825626427227928776156164172180189197205213221230238246254263271279287295     **Obese****Extreme Obesity**BMI373839404142434445464748495051525354**Height                  (inches)****Body Weight                   (pounds)**58177181186191196201205210215220224229234239244248253258591831881931982032082122172222272322372422472522572622676018919419920420921522022523023524024525025526126627127661195201206211217222227232238243248254259264269275280285622022072132182242292352402462512562622672732782842892956320821422022523123724224825425926527027828228729329930464215221227232238244250256262267273279285291296302308314652222282342402462522582642702762822882943003063123183246622923524124725326026627227828429129730330931532232833467236242249255261268274280287293299306312319325331338344682432492562622692762822892953023083153223283353413483546925025726327027728429129730431131832433133834535135836570257264271278285292299306313320327334341348355362369376712652722792862933013083153223293383433513583653723793867227227928729430230931632433133834635336136837538339039773280288295302310318325333340348355363371378386393401408742872953033113193263343423503583653733813893964044124207529530331131932733534335135936737538339139940741542343176304312320328336344353361369377385394402410418426435443  *Source*: Adapted from *Clinical Guidelines               on the Identification, Evaluation, and Treatment of Overweight and               Obesity in Adults: The Evidence Report.** pdf versions require the free               Adobe® Acrobat Reader software for viewing.     - Blood pressure.  Blood pressure is expressed as two numbers                 that represent pressure in your blood vessels when your heart                 is beating (systolic pressure) and when it is resting (diastolic                 pressure). The numbers are usually written with a slash--for example,                 140/90, which is expressed as "140 over 90." For the general population,                 blood pressure below 130/85 is considered normal, although people                 whose blood pressure is slightly elevated and who have no additional                 risk factors for heart disease may be advised to make lifestyle                 changes--that is, diet and exercise--rather than take blood pressure                 medicines. People who have diabetes, however, should take whatever                 steps necessary, including lifestyle changes and medicine, to                 reach a blood pressure goal of below 130/80.   
  - Cholesterol.  Your cholesterol is usually reported with                 three values: low density lipoprotein (LDL) cholesterol, high                 density lipoprotein (HDL) cholesterol, and total cholesterol.                 LDL cholesterol is sometimes called "bad" cholesterol, while HDL                 cholesterol is called "good" cholesterol. To lower your risk of                 cardiovascular problems if you have diabetes, you should try to                 keep your LDL cholesterol below 100 and your total cholesterol                 below 200.  If you have metabolic syndrome, your doctor may recommend weight               loss with diet and exercise, as well as medication to lower your               cholesterol and blood pressure levels.   Stop Smoking  In addition to increasing your risk of cancer and cardiovascular               disease, smoking contributes to insulin resistance. Quitting smoking               is not easy, but it could be the single smartest thing you can do               to improve your health. You will reduce your risk for respiratory               problems, lung cancer, and diabetes.   [Top]     Can medicines help?  Two classes of drugs can improve response to insulin and are used               by prescription for type 2 diabetes--biguanides and thiazolidinediones.               Other medicines used for diabetes act by other mechanisms. Alpha-glucosidase               inhibitors restrict or delay the absorption of carbohydrates after               eating, resulting in a slower rise of blood glucose levels. Sulfonylureas               and meglitinides increase insulin production.   The DPP showed that the diabetes drug metformin, a biguanide, reduced               the risk of diabetes in those with pre-diabetes but was much less               successful than losing weight and increasing activity. In another               study, treatment with troglitazone, a thiazolidinedione later withdrawn               from the market following reports of liver toxicity, delayed or               prevented type 2 diabetes in Hispanic women with a history of gestational               diabetes. Acarbose, an alpha-glucosidase inhibitor, has been effective               in delaying development of type 2 diabetes. Additional studies using               other diabetes medicines and some types of blood pressure medicines               to prevent diabetes are under way. No drug has been approved by               the Food and Drug Administration (FDA) specifically for insulin               resistance or pre-diabetes.   [Top]   Hope Through Research  Researchers sponsored by the National Institute of Diabetes and               Digestive and Kidney Diseases conducted the DPP to find the most               effective ways to prevent or delay the onset of type 2 diabetes.               Volunteers were recruited from groups known to be at particularly               high risk for IGT and type 2 diabetes. The study was designed to               compare the effectiveness of lifestyle changes (weight loss through               exercise and diet) with drug therapy (metformin). A control group               received a placebo and information on diet and exercise. Participants               assigned to the intensive lifestyle intervention reduced their risk               of getting type 2 diabetes by 58 percent over 3 years. Participants               treated with metformin reduced their risk by 31 percent. Metformin               is not currently approved for use in preventing diabetes, but the               FDA may determine whether to make diabetes prevention an added indication               for this drug. In any event, the DPP demonstrates that a healthy               diet and exercise are the most effective treatment for insulin resistance               and the prediabetic states of IFG and IGT.  [Top]   Points to Remember    - Glucose is the simple sugar that is the main source of energy                 for the body's cells.    - Insulin helps cells take in blood glucose and convert it to                 energy.    - If you have insulin resistance, your body's cells do not respond                 well to insulin.    - Insulin resistance is a stepping-stone to type 2 diabetes.    - Lack of exercise and excess weight contribute to insulin resistance.    - Engaging in moderate physical activity and maintaining proper                 weight can help prevent insulin resistance.    - Insulin resistance plays a role in the development of cardiovascular                 disease, which damages the heart and blood vessels.    - Controlling blood pressure and LDL cholesterol and not smoking                 can also help prevent cardiovascular problems.    - The Diabetes Prevention Program confirmed that exercise and                 a low-calorie, low-fat diet are the best ways to prevent type                 2 diabetes.  [Top]     National Diabetes Information Clearinghouse  
1 Information Way                Bethesda, MD 20892-3570                Email: ndic@info.niddk.nih.gov
  The National Diabetes Information Clearinghouse (NDIC) is a service               of the National Institute of Diabetes and Digestive and Kidney Diseases               (NIDDK). The NIDDK is part of the National Institutes of Health               under the U.S. Department of Health and Human Services. Established               in 1978, the clearinghouse provides information about diabetes to               people with diabetes and to their families, health care professionals,               and the public. NDIC answers inquiries, develops and distributes               publications, and works closely with professional and patient organizations               and Government agencies to coordinate resources about diabetes.   Publications produced by the clearinghouse are carefully reviewed               by both NIDDK scientists and outside experts. This fact sheet was               reviewed by George A. Bray, M.D., Pennington Biomedical Research               Center, Louisiana State University; and Richard F. Hamman, M.D.,               Dr.P.H., Department of Preventive Medicine and Biometrics, University               of Colorado Health Sciences Center.   This e-text is not copyrighted. The clearinghouse encourages users               of this e-pub to duplicate and distribute as many copies as desired.                 NIH Publication No. 04-4893              May 2004             [ Top ]                 
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